What Are Therapeutic
Communities?
See page 11.
Therapeutic communities (TCs) are a common form of long-term residential treatment for
substance use disorders (SUDs).
Residential treatment for SUDs emerged in the late 1950s out of
the self-help recovery movement, which included groups such as Alcoholics Anonymous. Some
such groups evolved into self-supporting and democratically run residences to support abstinence
and recovery from drug use (Sacks & Sacks, 2010). Examples have included community lodges,
Oxford Houses, and TCs. The first TC was the Synanon residential rehabilitation community,
founded in 1958 in California. During the 1960s, the first generation of TCs spread throughout
areas of the United States, and today the TC approach (see “What is a Therapeutic Community’s
Approach?”) has been adopted in more than 65 countries around the world (Bunt et al., 2008).
Therapeutic
Communities
Historically, TCs have seen themselves as a mutual self-help alternative to medically oriented strategies to address addiction and most have not allowed program participants to use medications of any kind, including medications such as methadone (a long-acting opioid agonist medication shown to be effective in treating opioid addiction and pain) (De Leon, 2000; De Leon, 2015). Over the past 30 years, TCs’ attitudes toward medications have gradually evolved, reflecting changing social attitudes toward addiction treatment and the scientific recognition of addiction as a medical disorder (De Leon, 2000; De Leon, 2015; Vanderplasschen et al., 2013). A growing number of TCs now take a comprehensive approach to recovery by addressing participants’ other health issues in addition to their SUDs, incorporating comprehensive medical treatment (Smith, 2012) and supporting participants receiving medications for addiction treatment or for other psychiatric disorders (see “How Are Therapeutic Communities Adapting to the Current Environment?”). Many of today’s TCs are also
offering shorter-term residential or outpatient day treatment (De Leon, 2012; De Leon & Wexler, 2009) in addition to long-term residential treatment.
TCs have also been adapted over time to address the
treatment needs of different populations. During the 1990s,
What is a Therapeutic
Community’s Approach?
recovery
Are Therapeutic
Communities Effective?
OUTCOMES
50
40
30
20
10
0
Cocaine Use Problem
Alcohol Use Suicidal Thoughtsor Attempts Full-time Work
34%
17% 18%
10%
16%
4%
28% 46%
More than 6 months in TC (n=159) Less than 6 months in TC (n=172)
Percent
What are the Fundamental
Components of Therapeutic
Communities?
rehabilitation
habilitation
CBT
is a form of psychotherapy that teaches people strategies to identify and correct
problematic behaviors in order to enhance self-control, stop drug use, and address
a range of other problems that often co-occur with them.
Motivational interviewing
is an evidence-based treatment and counseling style that
helps patients explore and resolve ambivalence about changing their behavior in a
focused and goal-directed way.
“Community as method”
is an essential and de
fi
ning approach of TCs in which
participating in a mutual-help community drives individual change and the attainment
of therapeutic goals.
How is Treatment
Provided in a Therapeutic
Community?
as they needed to progress through these treatment
TC for a minimum of 90 days fare better than those
ranging from engagement to residential treatment to
How Do Therapeutic
Communities Treat
Populations with
Special Needs?
People with psychiatric comorbidities
Homeless individuals
there is a greater emphasis on assisting program
and employment gains during both residential TC
Women
Adolescents
How Are Therapeutic
Communities Integrated
into the Criminal
Justice System?
60 80 100 40 20 0 87%91% 79% 86% 57% 55% 31% 56% 25% 44% 21% 39% Mental Health Treatment Therapeutic Community
Percent
SUBSTANCE USE OUTCOMES
50 60 40 30 20 10 0Re-incareration Any Criminal
Activity Criminal Activity Related to Substance Use
5% 33% 42% 30% 58% Percent
Source: Sacks et al., 2004a.
50 60
40 30 20
10 0
Abstinence
From Drugs (After Work Release)Employment
32%
10%
55%
45%
Standard Supervision Re-entry TC Treatment
Percent
SUBSTANCE USE OUTCOMES
Source: Butzin et al., 2005.
How Are Therapeutic
Communities Adapting to
the Current Environment?
Provision of medications for
addiction treatment
Shortened planned treatment durations
and outpatient programs
on TCs to shorten planned treatment durations even
Aromin AR, Galanter M, Solhkah R, Dermatis H, Bunt G. Preference for spirituality and twelve-step-oriented approaches among adolescents in a residential therapeutic community.
J Addic Dis. 2008;25:89 – 96.
Becan JE, Knight DK, Crawley RD, Joe GW, Flynn PM. Effectiveness of the Treatment Readiness and Induction Program for increasing
adolescent motivation for change. J Subst Abuse Treat.
2015;50:38 – 49.
Belenko S, Hiller M, Hamilton L. Treating substance use disorders in the criminal justice system. Curr Psychiatry Rep. 2013;15:414.
Buck JA. The looming expansion and transformation of public
substance abuse treatment under the Affordable Care Act. Health
Affairs. 2011;30:1402 – 1410.
Bunt GC, Muehlbach B, Moed CO. The Therapeutic Community: international perspective. Subst Abuse. 2008;29:81 – 87.
Burdon WM, Dang J, Prendergast ML, Messina NP, Farabee D. Differential effectiveness of residential versus outpatient aftercare for parolees from prison based therapeutic community treatment
programs. Subst Abuse Treat Prev Policy. 2007;2:16.
Butzin CA, Martin SS, Inciardi JA. Treatment during transition from
prison to community and subsequent illicit drug use. J Subst Abuse
Treat. 2005;28(4):351 – 358.
Cooperman NA, Falkin GP, Cleland C. Changes in women’s sexual risk
behaviors after therapeutic community treatment. AIDS Educ Prev.
2005;17:157 – 169.
Covington SS, Bloom BE. Gender-responsive treatment and services in correctional settings. In: Leeder E, ed. Inside and Out: Women,
Prison, and Therapy. New York, NY: Haworth Press; 2006:9 – 24.
De Leon G, Wexler H. The therapeutic community for addictions: an
evolving knowledge base. Journal of Drug Issues. 2009;39:167 – 178.
De Leon G. The Therapeutic Community: Theory, Model, and Method.
New York, NY: Springer Publishing Company; 2000.
De Leon G. Is the therapeutic community an evidence-based
treatment? What the evidence says. Ther Communities.
2010;31:104 – 128.
De Leon G. Therapeutic communities: today and tomorrow. Presentation to Drugs and Society Seminar, Columbia University, May 2012.
De Leon G. Therapeutic Communities. In: Galanter M, Kleber HD,
Brady KT, eds. The American Psychiatric Textbook of Substance
Abuse Treatment. 5th ed. Washington, DC: American Psychiatric
Publishing Inc.; 2015:511 – 530.
Dye MH, Ducharme LJ, Johnson JA, Knudsen HK, Roman PM. Modified therapeutic communities and adherence to traditional elements. J Psychoactive Drugs. 2009;41:275 – 283.
Dye MH, Roman PM, Knudsen HK, Johnson JA. The availability of integrated care in a national sample of therapeutic communities.
J Behav Health Serv Res. 2012;39:1 – 27.
Edelen MO, Tucker JS, Wenzel, SL, et al. Treatment process in the therapeutic community: associations with retention and outcomes
among adolescent residential clients. J Subst Abuse Treat.
2007;32:415 – 421.
Foster M, Nathan S, Ferry M. The experience of drug-dependent
adolescents in a therapeutic community. Drug Alcohol Rev.
2010;29:531 – 539.
Fullerton CA, Kim M, Thomas CP, et al. Medication-assisted treatment with methadone: assessing the evidence.
Psychiatr Serv. 2014;65:146 – 157.
Gordon J, Moriarty L, Grant P. The impact of juvenile residential
treatment centre on minority offenders’. J Contemp Crim Justice.
2000;16:194 – 208.
Greenberg B, Hall DH, Sorensen JL. Methadone maintenance therapy in residential therapeutic community settings: challenges and promise.
J Psychoactive Drugs. 2007;39:203 – 210.
Hawke JM, Jainchill N, De Leon G. Posttreatment victimization and violence among adolescents following residential drug treatment.
Child Maltreat. 2003;8:58 – 71.
Hendershot CS, Witkiewitz K, George WH, Marlatt GA. Relapse
prevention for addictive behaviors. Subst Abuse Treat Prev Policy.
2011;6:17.
Hubbard RL, Craddock SG, Anderson J. Overview of 5-year followup outcomes in the drug abuse treatment outcome studies (DATOS).
J Subst Abuse Treat. 2003;25:125 – 134.
Jainchill N. Therapeutic communities for adolescents: the same and
not the same. In De Leon G, ed. Community As Method: Therapeutic
Communities for Special Populations and Special Settings. Westport,
CT: Praeger; 1997:161 – 178.
Jainchill N, Hawke J, De Leon G, Yagelka J. Adolescents in therapeutic communities: one year posttreatment outcomes.
J Psychoactive Drugs. 2000;32:81 – 94.
Jainchill N, Hawke J, Messina M. Post-treatment outcomes among adjudicated adolescent males and females in modified therapeutic
community treatment. Subst Use Misuse. 2005;40:975 – 996.
Martin SS, O’Connell DJ, Paternoster R, Bachman RD. The long and winding road to desistance from crime for drug-involved offenders: the long-term influence of therapeutic community treatment on re-arrest. Journal of Drug Issues. 2011;41:179 – 196.
Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.
Cochrane Database Syst Rev. 2003;(2):CD002209.
Morral AR, McCaffrey DF, Ridgeway G. Effectiveness of community-based treatment for substance-abusing adolescents: 12-month outcomes of youths entering Phoenix Academy or alternative probation dispositions. Psychol Addict Behav. 2004;18:257 – 268.
Perfas FB, Spross S. Why the concept-based therapeutic
community can no longer be called drug-free. J Psychoactive Drugs.
2007;39:69 – 79.
Perry PD, Hedges Duroy TL. Adolescent and young adult heroin and non heroin users: a quantitative and qualitative study of experiences
in a therapeutic community. J Psychoactive Drugs. 2004;36:75 – 84.
Prendergast ML, Hall EA, Wexler HK, Melnick G, Yan C. Amity
Prison-based therapeutic community: 5-year outcomes. Prison Journal.
2004;84:36 – 60.
Rivard JC, Bloom SL, Abramovitz R, et al. Assessing the implementation and effects of a trauma-focused intervention for youths in residential treatment. Psychiatr Q. 2003;74:137 – 154.
Sacks JY, McKendrick K, Hamilton Z. A randomized clinical trial of a therapeutic community treatment for female inmates: outcomes at 6 and 12 months after prison release. J Addic Dis. 2012;31:258 – 269.
Sacks S, Sacks JY. Research on the effectiveness of the modified therapeutic community for persons with co-occurring substance use
and mental disorders. Ther Communities. 2010;31:176 – 211.
Sacks S, Banks S, McKendrick K, Sacks JY. Modified therapeutic community for co-occurring disorders: a summary of four studies.
J Subst Abuse Treat. 2008;34:112 – 122.
Sacks S, Chaple M, Sacks JY, McKendrick K, Cleland CM. Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: crime outcomes.
J Subst Abuse Treat. 2012;42:247 – 59.
Sacks S, De Leon G, Sacks JY, McKendrick K, Brown, BS. TC-oriented supported housing for homeless MICAs.
J Psychoactive Drugs. 2003;35:355 – 366.
Sacks S, McKendrick K, Sacks JY, Banks S, Harle M. Enhanced outpatient treatment for co-occurring disorders: main outcomes.
J Subst Abuse Treat. 2008;34:48 – 60.
Sacks S, Sacks JY, McKendrick K, Banks S, Stommel J. Modified TC for MICA offenders: crime outcomes.
Behav Sci Law. 2004;22:477 – 501.
Sacks S, Sacks JY, McKendrick K, Pearson FS, Banks S, Harle M. Outcomes from a therapeutic community for homeless addicted
mothers and their children. Adm Policy Ment Health. 2004;31:313 – 338.
Simpson DD. Treatment for drug abuse. Follow-up outcomes and length of time spent. Arch Gen Psychiatry. 1981;38:875-880.
Skinner DC. A modified therapeutic community for homeless persons with co-occurring disorders of substance abuse and mental illness in
a shelter: an outcome study. Subst Use Misuse. 2005;40:483 – 497.
Smith DE. The medicalization of therapeutic communities in the era of health care reform. J Psychoactive Drugs. 2012;44:93 – 95.
Stevens SJ, Arbiter N, McGrath R. Women and children: therapeutic
community substance abuse treatment. In De Leon G, ed. Community
As Method: Therapeutic Communities for Special Populations and
Special Settings. Westport, CT: Praeger; 1997:129 – 142.
Sullivan CJ, McKendrick K, Sacks S, Banks S. Modified therapeutic community treatment for offenders with MICA disorders: substance
use outcomes. Am J Drug Alcohol Abuse. 2007;33:823 – 832.
Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence.
Psychiatr Serv. 2014;65:158 – 170.
Vanderplasschen W, Colpaert K, Autriquem M, et al. Therapeutic communities for addictions: a review of their effectiveness from a recovery-oriented perspective. Scientific World Journal.
2013;2013:427817.
Vanderplasschen W, Vandevelde S, Broekaert E. Therapeutic communities for treating addicitions in Europe: evidence, current
practices and future challenges. European Monitoring Centre for
Drugs and Drug Addiction. 2014.
Van Stelle KR, Blumer C, Moberg DP. Treatment retention of dually
diagnosed offenders in an institutional therapeutic community. Behav
Sci Law. 2004;22:585 – 597.
Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted
therapies—tackling the opioid-overdose epidemic. N Engl J Med.
2014;370:2063 – 2066.
Warren K, Hiance D, Doogan N, De Leon G, Phillips G. Verbal feedback in therapeutic communities: pull-ups and reciprocated
pull-ups as predictors of graduation. J Subst Abuse Treat.
2013;44:361 – 368.
Warren KL, Doogan N, De Leon G, Phillips GS, Moody J, Hodge A. Short-run pro-social behavior in response to receiving corrections
and affirmations in three therapeutic communities. J Offender
Rehabil. 2013;52:270 – 286.
Wexler HK, Williams R. The Stay ‘n Out therapeutic community:
prison treatment for substance abusers. J Psychoactive Drugs.
1986;18:221 – 230.
Wexler HK, Prendergast ML. Therapeutic communities in United States’ prisons: effectiveness and challenges.
